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General NPI Number Information
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NPI Number | 1194929943
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Entity Type | Organization
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Legal Business Name | KENTUCKY LAPAROSCOPIC & ADVANCED SURGICAL SPECIALISTS, PLLC
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Dates
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Enumeration Date | 06/14/2007
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Last Update Date | 03/12/2009
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Provider Practice Location Address
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Address Line | 5322 KY ROUTE 321 SUITE 1
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City | PRESTONSBURG
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State | KY
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Zip | 41653-9114
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Country | US
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Telephone | 606-886-8240
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Fax | 606-886-8243
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Provider Business Mailing Address
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Address Line | PO BOX 1239
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City | PRESTONSBURG
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State | KY
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Zip | 41653-5239
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Country | US
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Telephone | 606-886-8240
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Fax | 606-886-8243
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Authorized Official
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Title or Position | OWNER
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Name | JODY MICHAEL JOHNSON
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Credential | D.O.
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Telephone | 606-886-8240
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 02979
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License Number State | KY
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